Stroke while taking anticoagulant

I am a 79 year old female who recently suffered an ischemic stroke while taking an anticoagulant and a low dose aspirin. Here is some of my history. I've had three ablations for atrial fibrillation, the last one in September of 2014. I have been in normal sinus rhythm since that ablation for more than 99% of the time. I am still in normal sinus rhythm. I do have a lot of premature heartbeats. I have a pacemaker which verifies that when it is checked.

The pacemaker was installed prior to my second ablation so that I could take the necessary medicine without causing me to have bradycardia (low heart rate). The only medicine I have been taking for a-fib for the past three years is Eliquis....no rhythm or rate control drugs. In February of 2017, I had a heart cath (because of the loss of my son where I developed the "broken heart syndrome") and showed no clogs arteries. I've also had a nuclear stress test and echos.

On June 23, it came as quite a shock to me when I had an ischemic stroke while taking Eliquis and low dose aspirin. It did not involve my carotid arteries, but traveled to the main artery to my brain where it seems it is often where a clot from the heart goes. I have no other history of clots in any other part of my body.

I am very fortunate that I was taking Eliquis and a low dose aspirin as the stroke could have been catastrophic had I not been taking an anticoagulant. It first affected the right side of my body and my speech...but both of these improved almost immediately and neither my body movement or speech has been impacted. However, my thinking process has suffered and that is my greatest weakness now. I find mental tasks to be exhausting and find that my cognition ability is impaired. I have spent a week in re-hab and am now at home. I am working with a speech therapist to improve my memory and cognitive skills.

I thought I was protected from stroke by taking Eliquis faithfully....and for a long period of time. It was quite a shock to me when I had the stroke.
The doctors have told me that I am very lucky that I was taking an anticoagulant and it looks like I will be making a complete recovery over a period of time. Of course, I am still taking Eliquis and will continue to do so.

This is what I am wondering...has anyone in this forum had an ischemic stroke while taking an anticoagulant? I thought I was protected, but apparently I was not. ( I should also add that stress may have been a factor for me.)

If you spot a lot of misspelled words in this long message,...that is because of the impairment I have.
I hope that I will get a response from anyone who has had a similar event and hear how they are doing.

Is the Eliquis dose 2.5mg twice per day or 5mg twice per day? It should be 5mg twice per day. I'd be surprised if it were not, but it bears mentioning that the drug does come in both doses.

I have always been taking 5 MG twice a day...not the lower dose.

So sorry about your stroke and I am glad that you are not in a bad way and are getting better.

There was a man on this board about a couple of months ago that said he was taking Padaxra for a couple of years then switched to Eliquis, a month or so later he had a stroke, he said he was having memory problems. I don't know how he is doing now perhaps he will see this and write in. I will try to find that post.

Liz

I found it:


Mike E [ PM ]
Re: Eliquis side effects
April 20, 2018 11:41AM Registered: 3 years ago
Posts: 98

In November of 2016 I requested my prescription be changed from Xeralto to Eliquis. I did not feel well on the Eliquis. I informed the NP of it and sent heart rhythm traces and was told to wait and see. By the end of Dec I had a stroke. The Eliquis was not working at all. The stroke was far worse than the worst of my AFIB (after three ablations). I would be very careful of any issues with Eliquis.


April 20, 2018 01:12PM Registered: 3 years ago
Posts: 98

Elizabeth,
I was taking 5 mg, one in the morning and one in the evening. My brain will never be the same. The stroke was in the left side of my brain and affected my right arm and leg and the forward part which stores lots of needed functions. My memory is lacking many needed things. I'm working hard to reclaim much lost at the time. I look normal to most people but I cannot talk about what I used to know. I'm walking pretty well now but I'm not as strong as I was before the stroke. I working on it. Thanks for asking, I'm getting better all the time.



Edited 2 time(s). Last edit at 07/12/2018 12:59AM by Elizabeth.

I'm sorry this happened to you. It is rare but it can happen with any of the anticoagulants. Do you know if any of your ablations resulted in your left atrial appendage (LAA) being isolated? If so, that can make you particularly vulnerable to clot formation in the LAA, which is where >90% of all atrial clots form. You might want to investigate an LAA occlusion procedure. That's a procedure where they either insert a device into the LAA to seal it, or clip it off from the outside with a minimally invasive surgical procedure. Such a procedure would reduce your chances of future strokes by over 90%.

Quote
wolfpack
Is the Eliquis dose 2.5mg twice per day or 5mg twice per day? It should be 5mg twice per day. I'd be surprised if it were not, but it bears mentioning that the drug does come in both doses.

Why does it have to be the high dose? Dr. Natalie has me on 2.5 twice a day. I also take a baby aspirin once a day per Dr. Natalie’s orders.
I am 60 years old.

I have had two Ablations with the Master of AFIB Ablation. The second one, they had to isolate the LAA and I failed “the test” due to having no A Wave into the mitral valve. . My flow rate was excellent ( 60) but no A wave.

Just wandering why you say it should be 5mg two times a day.



Edited 2 time(s). Last edit at 07/15/2018 09:20AM by smackman.

Quote
smackman
Just wandering why you say it should be 5mg two times a day.

It doesn't always have to be, but 5 mg BID is the standard dosing for anticoagulation in AF patients with a CHADS2VASC score of 2 or greater. Certainly once one has established a doctor/patient relationship with an EP things can be changed. However, in the original poster's case I don't think anyone would recommend reducing the DOAC in light of an embolic event already having occurred at the standard dosage.

Carey, I got a question for you. I watched dr. Wolf presentation regarding his procedure (Wolf Mini maze) where he also talks about LAA closure and various methods of doing it. He claims that surgical removal is superior method to both Watchman and Lariat devices. Have you seen that? If you did just want to hear your thoughts about it. He claims that this is relatively simple procedure which takes about 30 min. You seem very knowledgable.
Deniss



Edited 1 time(s). Last edit at 07/12/2018 08:01PM by dartisskis.

Thanks for all the responses. I saw my GP today and she says that strokes can and do occur while a person is taking an anticoagulant...as was my case. It may not have even been related to atrial fibrillation as I was in normal sinus rhythm the entire time of the event. She says that even small amounts of plaque can form in an artery causing an event such as this. I had a heart cath last year which did not show any blockage...but it is possible that it occurred since then.

Carey, I will see my EP in September and ask about the LAA being isolated in any of my 3 ablations. I don't know.
At any rate, I feel very fortunate to be having a good recovery...but still have a way to go with thought processing.... but my doctor, home health nurses, and speech therapist say I am doing well
Thanks again to all who have commented,.

Quote
dartisskis
I watched dr. Wolf presentation regarding his procedure (Wolf Mini maze) where he also talks about LAA closure and various methods of doing it. He claims that surgical removal is superior method to both Watchman and Lariat devices.

They are superior in some ways, but they require a surgical procedure. It may be short but it means making holes in your chest and that means weeks of recovery time. Endocardial devices such as Watchman take about an hour and there is no recovery time. You'll have a few days of lifting restrictions due to the insertion sites in your groin, but other than that you'll be back to normal immediately. So it's a tradeoff. If I were doing a surgical procedure anyway, such as a Maze, then I would definitely have the LAA removed, sutured, or clipped during that procedure. But there's no way I would undergo chest surgery just to close my LAA when devices like Watchman exist.

I would certainly try the Watchman procedure rather than a chest surgery. My sister-in-law had the Watchman procedure because she could not take any coagulants. It seems to have worked well for her....although it does not cure the a-fib. My a-fib has been controlled since my 3rd ablation in September of 2014 and I am in NSR now.

Carey - I'm curious...

After the Watchman placement, don't they require the patient to remain on Eliquis for a period of time until the device endothelizes completely? Is there a screening test that's done to confirm the placement and the "completeness" of the endothelization?
Thanks.

Jackie

Smackman... I'm also on Eliquis 2.5 mg twice a day after the Natale LAA and the followup procedure after that.
It's interesting that Dr. Natale recommended additional aspirin... Did he elaborate on why you should add the aspirin as well?


The FDA FDA prescribing information, it says this:

5.2 Bleeding
ELIQUIS increases the risk of bleeding and can
cause serious, potentially fatal, bleeding
[see Dosage and Administration (2.2) and Adverse Reactions (6.1)]
.
Concomitant use of drugs affecting hemostasis
increases the risk of bleeding. These include
aspirin and other antiplatelet agents, other antico-
agulants, heparin, thrombolytic agents, selective
serotonin reuptake inhibitors, serotonin norepinephrine
reuptake inhibitor, and nonsteroidal anti-inflammatory drugs (NSAIDs)
[see Drug Interactions (7.3)]

Bleeding

Eliquis increases the risk of bleeding and can cause serious, potentially fatal, bleeding [see Dosage and Administration (2.1) and Adverse Reactions (6.1)].

Concomitant use of drugs affecting hemostasis increases the risk of bleeding. These include aspirin and other antiplatelet agents, other anticoagulants, heparin, thrombolytic agents, selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors, and nonsteroidal anti-inflammatory drugs (NSAIDs) [see Drug Interactions (7.3)].
[www.drugs.com]

Jackie


.

Quote
Jackie
After the Watchman placement, don't they require the patient to remain on Eliquis for a period of time until the device endothelizes completely? Is there a screening test that's done to confirm the placement and the "completeness" of the endothelization?

Yes to both questions. Following the procedure I'll be on Eliquis, clopidogrel, and aspirin for 45 days. At 45 days they'll do a repeat TEE to verify that there's no clot on the device and there's no blood flow through/around it, indicating it has been fully endothelialized. If so, I can stop the Eliquis at that point, but the clopidogrel and aspirin will be continued for six months. The FDA recommendation is to continue aspirin for life, but word from the EPs is that's mostly just CYA and isn't really necessary. It's not the practice in Europe. Low-dose aspirin has some other benefits, so I might go ahead and continue it anyway.

OK. Thanks for the info.
Jackie

My cardiologist has had me taking a low dose aspirin in addition to Eliquis for a long time because the two act in different ways. I have never taken any NSAID or other blood thinning agents in many years. Some anti-depressants are also not recommended. While I was taking both Eliquis and low dose aspirin when I had my stroke, the Eliquis certain made a difference in the severity of the stroke.

You have a very positive attitude, which is wonderful---however, my question would be you are on Eliquis and aspirin, yet you still got a stroke, why? You are saying that you believe your stroke was not as bad because of the drugs, I certainly don't know, but there are stats out there that people have had strokes yet were on eliquis, you were not having AF for some time, I say your stroke should not have happened.

Liz

Quote
Elizabeth
You are saying that you believe your stroke was not as bad because of the drugs, I certainly don't know, but there are stats out there that people have had strokes yet were on eliquis, you were not having AF for some time, I say your stroke should not have happened.

Strokes happen to people on anticoagulants. Rare, but it happens. And that's true of all anticoagulants, not just Eliquis.

It's good to keep in mind that blood clots aren't the only cause of strokes. For example, pieces of arterial plaque can break off and travel to the brain, causing a stroke. An anticoagulant won't prevent that. Strokes can also be hemorrhagic, which anticoagulants make more likely, not less.

My 2 cents about conversations above:

Elizabeth, so sorry to hear of your stroke and struggles to recovery. So happy you are getting stronger every day. I understand your frustration. It can be isolating.
I had a brain infection in your same area and can relate to your struggles with cognition. Know the brain does have some capacity for growth and repair. You will keep getting better! It's nice you have a speech therapist to support you in re-learning.

Eliquis dose has to do with weight also. I read that if one is 130# or under the dose is cut in half (2.5 mg bid).

Elizabeth, Perhaps your stroke was from calcified debris and not a clot? The aorta is a common source.

The mitral valve A wave is the atrial kick or contraction. It is not seen when one is in a-fib or heart rate is high enough that the two waves fuse.

If anyone is having a surgical closure of the appendage you might benefit from a discussion with the surgeon. I've seen ones on echo that still have a little pouch big enough to require continued anticoagulants. I'm not sure if it has to do with anatomy, like muscle bundles making it hard to get perfect, or the surgeons fault.

Libby, Libby, you have the wrong person that has written on this topic, the name is Justmetoo not Elizabeth.

Liz

So sorry,
See, just an example of how my brain doesn't work right!

Just curious, is there a way to measure in the blood if Eliquis is working or not?



Edited 1 time(s). Last edit at 07/14/2018 11:36AM by libby.

Quote
libby
Just curious, is there a way to measure in the blood if Eliquis is working or not?

No. If you're taking it as directed, it's working.

The NOACs aren't like warfarin. Their effect doesn't vary from person to person and day to day like warfarin does. They're predictable, they have the same effect every time you take them, and they aren't affected by what you eat or your insulin levels or anything like that. There's no reason to doubt they're working if you're taking them as directed.

Quote
Carey

Just curious, is there a way to measure in the blood if Eliquis is working or not?

No. If you're taking it as directed, it's working.

The NOACs aren't like warfarin. Their effect doesn't vary from person to person and day to day like warfarin does. They're predictable, they have the same effect every time you take them, and they aren't affected by what you eat or your insulin levels or anything like that. There's no reason to doubt they're working if you're taking them as directed.

A true believer

Quote
Libby

Just curious, is there a way to measure in the blood if Eliquis is working or not?

Only one way I know of is to be in a situation where you have a clot that you are monitoring. I lucked out being in that situation, so could see it wasn't working after 4 TEE's.



Edited 1 time(s). Last edit at 07/14/2018 01:27PM by jpeters.

In response to previous posts....I have been taking Eliquis for many years at the standard dosage and will continue to take it. The neurologist is the one who told me that my stroke could have been much more severe if I had not been on an anti-coagulant. He said the anti-coagulant probably caused the small clot to dissolve and perhaps "scatter" (like a shower) into smaller particles. While he was familiar with my a-fib history and ablations (through records which were in the same hospital system).....I think he assumed that the clot was probably the result of an a-fib episode. However, since I have been in NSR for almost 4 years since my last ablation....and remained in NSR after the stroke....I am not certain that it was caused by a clot from the left appendage. I don't guess there is any way to know for sure. My GP also suggested that a bit of calcified plaque can also result in a stroke...and that it is not extremely rare for that to happen....in which case, I don't suppose an anticoagulant might make a difference. I had a heart cath in February of last year and did not have any arterial blockage nor require any stents.
So I suppose the exact reason for my stroke is still something of a mystery. Maybe if I did not have the pacemaker, an MRI would have been more definitive than the CT Scan.
At any rate, I am very thankful that I have recovered with no body weakness or speech impairment....just the cognitive issues that I hope will repair themselves in time and with the additional help of speech therapy for a while. I once was a good speller...but not so now!! I have to be careful not to be "dyslexic" when typing a post. I hope my ability to concentrate improves too as I do get mental fatigue when attempting some things.
But yes....Eliquis and I are still married and I will continue to take it in the event that my a-fib episodes return at some time in the future...along with the baby aspirin too. Thanks to all who have commented!

Quote
JustMeToo
In response to previous posts....I have been taking Eliquis for many years at the standard dosage and will continue to take it. The neurologist is the one who told me that my stroke could have been much more severe if I had not been on an anti-coagulant. He said the anti-coagulant probably caused the small clot to dissolve and perhaps "scatter" (like a shower) into smaller particles.

I'm by no means an expert on clots, but my understanding is that the anti-coagulent doesn't dissolve the clot, it just keeps new clots from forming. The body will dissolve the clot, and does that by turning the crusty clot into a liquid. I had a large mass of sludge, which my body got rid of as soon as I switched anti-coagulents. If it broke it down into little crusty fragments, trust me, I'd be dead.

Libby - Just curious, is there a way to measure in the blood if Eliquis is working or not?

Carey - No. If you're taking it as directed, it's working.

JPeters - Only one way I know of is to be in a situation where you have a clot that you are monitoring.... could see it (Eliquis) wasn't working after 4 TEE's.

So if Eliquis works the same for everyone, why have some people had strokes or clots that didn't dissolve until they switched to Coumadin?



Edited 2 time(s). Last edit at 07/15/2018 01:39AM by libby.

Following are two links that indicate Eliquis does function to break up clots.
[www.medicaldaily.com]
[www.eliquis.bmscustomerconnect.com]

Moreover, an important consideration for everyone is to know the key inflammatory markers (by testing) that can underlie clot formation...as outlined in several posts on this topic. Links below. When inflammatory processes exist, then, in some individuals, that's a concern as is elevated fibrinogen.

Reactive Oxygen Species (ROS) and inflammation are also contributors. [www.google.com]

Previous posts on Inflammation and Clot Risk and the test markers to check to help reduce the clot risk factors.

Silent Inflammation – Risk Marker for Stroke, Heart Attack & Much More
[www.afibbers.org]

Sticky, thick blood - Risk of Stroke and MI
[www.afibbers.org]

Clot Risk
[www.afibbers.org]

Jackie

Quote
Jackie
Smackman... I'm also on Eliquis 2.5 mg twice a day after the Natale LAA and the followup procedure after that.
It's interesting that Dr. Natale recommended additional aspirin... Did he elaborate on why you should add the aspirin as well?


The FDA FDA prescribing information, it says this:

5.2 Bleeding
ELIQUIS increases the risk of bleeding and can
cause serious, potentially fatal, bleeding

.
Concomitant use of drugs affecting hemostasis
increases the risk of bleeding. These include
aspirin and other antiplatelet agents, other antico-
agulants, heparin, thrombolytic agents, selective
serotonin reuptake inhibitors, serotonin norepinephrine
reuptake inhibitor, and nonsteroidal anti-inflammatory drugs (NSAIDs)


Bleeding

Eliquis increases the risk of bleeding and can cause serious, potentially fatal, bleeding .

Concomitant use of drugs affecting hemostasis increases the risk of bleeding. These include aspirin and other antiplatelet agents, other anticoagulants, heparin, thrombolytic agents, selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors, and nonsteroidal anti-inflammatory drugs (NSAIDs) .
[www.drugs.com]

Jackie


.

The aspirin is taken because I have a stent installed. This was done in 2012. Dr. Natalie actually had me taking a 325 mg aspirin 1x a day and reduced it to 81 mg over 2 years ago. Also, The Cardiologist who placed the stent is also adamant that I should continue to take a 81 mg aspirin for life.
From what I have read from reputable websites, this seems to be standard protocol for stents. All I am doing is following 2 Doctors orders.



Edited 1 time(s). Last edit at 07/15/2018 09:46AM by smackman.

Quote
Jackie
Following are two links that indicate Eliquis does function to break up clots.
[www.medicaldaily.com]
[www.eliquis.bmscustomerconnect.com]

The frequently quoted ARISTOTLE study: "Funded by Bristol-Myers Squibb and Pfizer; ARISTOTLE ClinicalTrials.gov number, NCT00412984.)"

[www.ncbi.nlm.nih.gov]

Effect size:

"The rate of the primary outcome was 1.27% per year in the apixaban group, as compared with 1.60% per year in the warfarin group"

"The rate of major bleeding was 2.13% per year in the apixaban group, as compared with 3.09% per year in the warfarin group"

"The rates of death from any cause were 3.52% and 3.94%, respectively"

Okay, so how much money did Bristol-Myers Squibb and Pfizer put into studying adverse effects and risks?
The big advertising feature is no tests required. Great for people who are non-compliant, or don't want to know what it's actually doing in their body. Individual differences? Changes in drug effectiveness over time? Extraneous variables not accounted for in the study? Tester bias?

Jackie, no anti-coagulent "breaks up clots."



Edited 2 time(s). Last edit at 07/15/2018 01:46PM by jpeters.

[www.strokeassociation.org]

According to a statement by the American Heart Association, taking aspirin within two days of an ischemic stroke reduces the severity of the stroke. In some cases, it prevents death. For long-term (meaning for the rest of your life unless otherwise specified by your physician) prevention, antiplatelet therapy is recommended primarily for people who have had a transient ischemic attack (TIA or “mini” stroke) or acute ischemic stroke.

JustMetoo said that she believes that because she was taking Eliquis her stroke was not real bad, well, perhaps it wasn't so bad because of the aspirin she was taking. I am glad she was taking the aspirin.

Liz



Edited 1 time(s). Last edit at 07/15/2018 02:43PM by Elizabeth.

My neurologist told me that the Eliquis had "dissolved" the clot causing my stroke and thus had prevented a more serious stroke episode resulting in more damage to my brain.. Since my cardiologist already had me taking a lo-dose aspirin each day as well, perhaps that played an important role too. There are so many conflicting opinions in this forum, I suppose that one can "believe" whatever they "want to believe"....and whatever seems "reasonable" to them. As for me, I will continue to take both Eliquis and lo-dose aspirin every day.

Quote
JPeters
no anti-coagulent "breaks up clots"

Patients with clots are put on heparin and/or coumadin and the clots dissolve over time. I'm sure I just don't understand the specifics clearly, but how exactly does that work?

Anticoagulants don't dissolve clots. They simply prevent it from getting larger and allow the body to dissolve it through its normal mechanisms.

Quote
JustMeToo
My sister-in-law had the Watchman procedure because she could not take any coagulants. It seems to have worked well for her...

Dear JustMeToo,

So sorry to hear of your stroke, but glad to hear things are getting better.

Regarding the quote from your earlier post above, would I be right to assume that your sister-in-law was required to take anticoagulants for a period before and after the Watchman procedure? Would anyone be permitted to undergo such a procedure without using anticoagulants before and after?

Thanks and sincere best wishes,

--Lance

Lance....yes, my sister-in-law who had the Watchman procedure was taking an anticoagulant before the she had the procedure and for a while afterwards...but I am not sure how long she had to take it afterwards. Your doctor will have that information. Now she no longer takes any anti-coagulants at all. The Watchman prevents clots from forming, but it does not stop a-fib. It is a good procedure for those who cannot take anti-coagulants because of bleeding or other side effects.

A good friend of mine just had a stroke as well while on elequis 5mg bid. He as AFib as well but no rate control.

They sent him home still on elequis adding the low dose of asperin. I can't believe they don't have him on rate control.